During the 2008/09 school year, REAP conducted their first study of anemia, its causes and its consequences in Shaanxi Province. According to results from the study, we found that anemia, or severe iron deficiency, is widespread in poor rural areas of the province, affecting nearly 40 percent of the students in the sample.

Problem

Poor nutrition was identified as the main source of anemia. When children received vitamins with minerals tablets (21) or 21 SUPER-VITA on a daily basis, anemia rates of these children fell and educational test scores rose.

Partly in response to our work and the policy briefs that were written based on the study results (and also due to their own commitment to better nutrition), in September 2009 the provincial governor of Shaanxi announced that he would be committing the province to providing every student in the province one egg (or one glass of milk) per day. His hope was that improved nutrition would result in healthier students and better educational performance. By any metric, the efforts of the provincial leadership are laudable. Eating an egg a day is beneficial for many students in Shaanxi's poor rural schools.

However, there was still another problem. If anemia is one of the most severe nutritional problems in Shaanxi's schools, then it contributes to low test scores. Unfortunately, the new initiative of the Shaanxi provincial governor should not be expected to do anything to overcome anemia. The reason is because eggs--despite being a nutritious food--contain almost no iron, and neither does milk. This then is the origins of our current project: Is One Egg Enough?

In the defense of the top leadership in the province, as soon as this was brought to their attention, they took immediate action. A document was sent, cautioning and reminding school principals that while giving one egg a day was required and improved nutrition, eggs only supply certain nutrients. A fully balanced diet is also required for good health, including foods with iron.

In addition, the province gave us their full support to test whether one egg is enough.

Goals

This study conducted by REAP seeks to:

Improve the nutrition and health of poor rural elementary school students, specifically in context of iron deficiency anemia, and to improve their educational performance.

Provide policymakers with objective study results that elucidate the impacts from the current initiative.

Evaluate the effects of additional policy-relevant options.

Specific objectives of this project are to assess effective means of improving health status (iron deficiency) and educational achievement of school-aged children, by comparing the effects from:

Providing information to students, parents and principals regarding the importance of balanced nutrition, in addition to consuming eggs.

Canteen staff prepare meals for boarding students.

Approach

Baseline: Month 1

Chosen from ten poverty counties in three prefectures of Shaanxi (these three prefectures only give eggs to boarding students in implementing the egg/milk initiative)-- Baoji, Hanzhong and Ankang (a total population of over 3.3 million) – 70 sample schools were randomly selected by REAP. From an initial canvas survey, enumerators first identified all rural elementary schools satisfying three requirements: a.) including six grades (complete schools or in Chinese—wanxiao); b.) having boarding facilities; c.) enrolling a minimum of 150 students, including at least 50 boarding students. In order for these schools to be comparable (“identical” in terms of the factors that we are controlling for), a balance test was conducted between the three sets of schools (two interventions and one control) using the information from the canvas survey.

To establish a baseline of health and learning abilities, our specific data collection instruments include: cognitive tests (math and Chinese); psychological tests; anthropometrics measurements; behavioral records; 24-hour food (nutrition) intake recalls; student surveys; household surveys; teacher surveys; and school surveys. Additionally, hemoglobin levels will be measured by a finger-prick Hemocue 201+ blood test, which will be administered by certified professional nurses from Xi’an Jiaotong University, School of Medicine. Only fourth grade students are included in this study.

Intervention: Months 2-7

Within our sample of schools, one group received the vitamin intervention; one group received the information treatment (for principals, canteen managers and parents); and one group served as our control schools.

Vitamin Treatment: In this group, all fourth grade students receivde a vitamin with minerals or 21 SUPER-VITA (in tablet form) daily, administered by their homeroom teachers who received instructions and training. Students who returned home on weekends received two multivitamins to take on their own, with clear directions.

Families and students received an intensive training course on preparing nutritious and cost-effective home meals (and meals at school or away from home), hygiene, food purchasing, and the relationship of these with health and education.

School staff (principals, cafeteria managers, and teachers) received an intensive training course on preparing nutritious and cost-effective school meals, hygiene, food purchasing, and the relationship of these with health and education.

Control Group: The remaining schools in our sample received no intervention. However, it is important to note that all boarding students in all schools consumed an egg every school day. Their baseline and evaluation health status and performance will be monitored by REAP, compared to the schools who received an intervention.

This study design allowed us to compare the impacts of egg consumption alone, egg consumption in conjunction with additional treatments (receiving vitamins or information) using boarding students, and also the impacts of receiving vitamins and information using the non-boarding students.

Results

Vitamin supplementation significantly improved both hemoglobin count and test scores among those students in the vitamin intervention group. However, the information intervention had more complicated results. Anemia rates fell significantly among girls whose parents received the training, but boys were unaffected. Furthermore, this improvement held only for girls who lived at home, girls who lived and ate most of their meals at boarding schools were unaffected.

This may be because parents only took action when they learned that their behavior may have been hurting their children. If their child, in their opinion, was not in danger of being anemic, then they did not take action by improving their child's nutrition. Since the initial hemoglobin levels of male students were higher than those of female students, it may have been that the parents of male students did not believe their son needed additional nutrients. While information training is slightly less expensive than vitamin supplementation, it is not nearly as effective, though it may make some progress toward narrowing the gender gap in nutrition.

In a parallel study, REAP evaluated whether one egg a day alone was effective in lowering anemia rates and improving test scores. In this study, REAP compared the anemia rates and test scores of an intervention group--who received one egg a day--to a control group, who received no improved nutrition. We found that one egg a day was insufficient to combat anemia and raise test scores. Overall, vitamin supplementation is the most effective and least expensive way to lower anemia rates and improve health and educational outcomes for China's poor rural students.